Clostridium difficile Ileitis in Pediatric Inflammatory Bowel Disease

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We present a case of Clostridium difficile ileitis in a 16-year-old girl with a history of Crohn disease (CD). The patient was diagnosed as having inflammatory bowel disease (IBD), initially believed to be ulcerative colitis, at age 5. She underwent total colectomy with diverting ileostomy at age 6 because of persistent bloody stools, diarrhea, and weight loss. Her diagnosis was later changed to CD because of continued weight loss and diarrhea despite colectomy. At the time of presentation, her CD had been managed with adalimumab since 9 years of age. She had a 1-month history of a “pulling sensation” at her stoma site and vague, crampy abdominal pain. She presented to the emergency department complaining about abdominal pain, yellow-green/nonbloody emesis, and increased stool output from her ileostomy. She denied fevers, rash, respiratory symptoms, or dysuria. Physical examination revealed diffuse abdominal tenderness with voluntary guarding, hypoactive bowel sounds, and brown stool output from the ileostomy. Abdominal computed tomography scan showed distal small bowel mucosal enhancement—consistent with inflammatory changes—and fluid-filled small bowel loops concerning for obstruction or ileus, which prompted hospital admission (Fig. 1). Laboratory findings on admission included white blood cell count of 16.1 × 103/μL with 76% neutrophils, C-reactive protein of 3.3 mg/dL (normal 0–1 mg/dL), total bilirubin of 2.3 mg/dL, and alkaline phosphatase of 167 U/L. Oral metronidazole (500 mg every 8 hours) was initiated after positive C difficile toxin assay (glutamate dehydrogenase [GDH]/toxin AB enzyme immunoassay, Alere, Orlando, FL) was obtained from stool. The patient was similarly tested 3 times for the presence of toxigenic C difficile during the previous 2 years for episodes of increased ostomy output and abdominal pain, all of which returned negative, thus decreasing the suspicion for toxin-producing strain carriage at this most recent visit.
On hospital day (HD) 1, oral antimicrobial therapy was changed to vancomycin (500 mg every 6 hours) because of vomiting, believed to be caused by metronidazole. Based on clinical and radiographic findings suggestive of small bowel obstruction, a catheter was placed in her stoma, her oral intake was restricted, and total parenteral nutrition was started. She developed fever to 38.5°C on HD 3 and began complaining about sore throat and sinus pressure, and was clinically diagnosed as having pharyngitis. Throat cultures for bacterial, viral, and fungal pathogens were negative. Epstein-Barr virus and cytomegalovirus serologies showed no evidence of acute infection. Repeat laboratory studies on HD 7 revealed increasing white blood cell count of 20.8 × 103/μL with 47% bands. Additional stool studies were obtained—including viral culture, Shiga toxin A antigen, and bacterial culture for Salmonella, Shigella, Yersinia, Escherichia coli 0157:H7, and Campylobacter—and all were negative. Following consultation with infectious diseases, IV metronidazole (10 mg/kg per dose q6 hours) was added to oral vancomycin for treatment of severe C difficile infection.
The patient's symptoms of possible small bowel obstruction were unchanged despite medical management; thus, the patient underwent ileostomy exploration and revision on HD 8. The surgeon identified pseudomembranous plaques that were limited to the dilated segment on direct visualization. The inflamed ostomy and adjacent dilated bowel segment were mobilized, explored, and resected. Histologic examination of the resected ileostomy and small bowel revealed focal erosion of the mucosal surface, mild villous atrophy, focal cryptitis, and rare crypt abscesses. The lamina propria showed increased plasma cells, histiocytic cells, and multinucleated giant cells within the submucosa. These findings were determined by the pathologist to be consistent with chronic active ileitis.

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